Observation, Reporting, and Recording

Course Code: REL-PAC-0-ORR

Hours: 1

Type: Online Course

Content Expiration Date: 6/30/2025

Learning Objectives:
Implement skills for good observation - what to watch for and how to observe.
Report your observations effectively using sound communication techniques.
Record your tasks and observations according to best practices.
Describe common types of documentation used for reporting your observations
Identify situations that caregivers have a legal obligation to report

Outline:
I.Observation, Reporting and Recording

II.Course Description

III.Course Objectives

IV.Checkpoints

V.Glossary

VI.The Care Team

VII.Important information

Obtaining Baseline information

Examples of baseline information

VIII.Communication

Communication skills

Making Observations and using the information

IX.Client Care Process

Reporting your Observations

Give Clear Descriptions

Use Plain Language

Be Descriptive

X.Directing Your information

When to Report

XI.Using Sbar to communicate

XII.Case Study: Beth

XIII.Checkpoint 2

XIV.Watching for signs and symptoms

Observing changes in senses

Levels of consciousness

Pain

Mood and Behavioral changes

Sudden Loss of Hearing

Fever and chills

Vital Signs

Heart and Lungs

Chest Pain

Changes in breathing

Cough

XV.Assessing Intake and Elimination

Excessive thirst

Changes in Appetite

Nausea and/or Vomiting

Dehydration signs

Changes in urine characteristics

Bowl changes

XVI.Assessing Skin, Extremities, functional ability

Changes in skin color

New wounds or drainage

Edema

Changes in functional ability

XVII.Checkpoint 3

XVIII.Use specifics

XIX.Recheck

XX.SBAR

XXI.Objective information

XXII.Documentation

Care Plans

Nursing Notes

Log Books

Electronic Medical Record

XXIII.Documentation Do's and Don'ts

Abbreviations

Meanings of Abbreviations

Meanings of Abbreviations

XXIV.Reporting Abuse and Neglect

Anonymous Reporting

XXV.Checkpoint 4

XXVI.Observations are Important

Communication

When to use SBAR

Baseline information

XXVII.Conclusion

XXVIII.End of lesson

Instructor: Laura L. Morgan, MSN, RN, NEA-BC

Laura L. Morgan, MSN, RN, CCRP, NEA-BC, currently serves as the Clinical Education Specialist at Lincoln County Medical Center in Ruidoso, New Mexico.  She plans, develops, implements, and evaluates educational programs for clinicians, using the most current research and clinical data, while fostering the implementation of evidence-based practice. Ms Morgan is an endorsed member of the Society of Clinical Research Associates, member of Sigma Theta Tau international honors Society of nursing, an instructor for Basic Life Support, Advance Cardiovascular Life support and a Board Certified Nurse Executive-Advanced from the American Nurses Credentialing Center.

Relias Learning will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.

Relias Learning has a grievance policy in place to facilitate reports of dissatisfaction. Relias Learning will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias Learning at support@reliaslearning.com.

Course Delivery Method and Format
Asynchronous Distance Learning with interactivity which includes quizzes with questions/answers, and posttests.